Kansas uses KanCare, a managed care delivery system, to implement its Medicaid Section 1115 demonstration program that operates concurrently with the State’s Section 1915(c) Home and Community-Based Services (HCBS) waivers. Kansas has contracted with three managed care organizations (MCOs) to deliver services to KanCare beneficiaries. The goals of KanCare are to provide efficient and effective health care services and ensure coordination of care and integration of physical and behavioral health services for children, pregnant women, and parents in the State’s Medicaid and Children’s Health Insurance Program (CHIP) programs.
Federal statutes (42 C.F.R. 438, subpart E & section 2103(f)(3) & C.F.R. 457.1240 & 1250) mandate that states using a managed care delivery system for all or some of their Medicaid and/or CHIP beneficiaries contract with a qualified independent external quality review organization (EQRO) to conduct an annual external quality review (EQR). The purpose of the annual review is to assess and monitor the quality of care provided to Medicaid and CHIP beneficiaries enrolled in the managed care organizations (MCOs) and to identify opportunities for quality improvement.
Kansas Department of Health and Environment (KDHE), Division of Health Care Finance (DHCF) currently contracts with the Kansas Foundation for Medical Care (KFMC) to serve as the EQRO for KanCare. The EQR-related activities are intended to (1) improve states’ ability to oversee and manage the MCOs they contract with for services, and (2) help MCOs improve their performance with respect to quality, timeliness, and access to care.
The posted reports are the annual EQR technical report, which summarizes findings on KanCare access and quality of care. The following activities were evaluated for each MCO:
• Information Systems Capabilities Assessment (ISCA)
• Performance Measure Validation (PMV)
• Review of Compliance with Medicaid and CHIP Managed Care Regulations (Compliance Review)
• Quality Assessment and Performance Improvement (QAPI)
• Performance Improvement Project (PIP) Validation
• Consumer Assessment of Health Care Providers and Systems (CAHPS® 1 ) Survey Validation
• Provider Survey Validation
KFMC also conducted the Home and Community Based Services (HCBS) CAHPS Survey and the Mental Health (MH) Consumer Perception Survey to evaluate the KanCare program, reflecting combined MCO performance.
Effective implementation of the EQR-related activities will facilitate Kansas’s efforts to purchase high-value care (rather than volume) and to achieve higher performing health care delivery systems for our Medicaid and CHIP beneficiaries.